Catch problems early in a lower cost setting! Not so simple, explain Harvard researchers who found 58% of retail clinic visits did not replace physician appointments, increasing costs.

Have employers found any health care gold at the end of a rainbow? Little, according to Northwestern University researchers in a recent American Journal of Accountable Care article. “Efforts to date have produced few promising strategies,” they concluded.

Does that mean employers should stop chasing rainbows? On the contrary! We need more employers chasing more rainbows. New rainbows. “No one really knows what will or won’t work. And we won’t know until we try some things,” urges Wal-Mart’s benefits leader, Sally Welborn.

More important than chasing rainbows, employers must become better health care buyers. Leveraging nearly $650 billion in annual spending, employers need to negotiate harder for better deals, form alliances to master the supply chain, work locally for greater value, align with government payment reforms wherever possible and contract directly with innovative providers.

Employers Negotiating Better

Given the money they spend on health care and their negotiating prowess as business people, employers should get better health care deals, especially on expensive drugs. They’re not, says Dr. Robert Galvin, formerly of General Electric and now CEO of Equity Healthcare.

“Baffling” is how he describes what he calls employers’ “weak-kneed behavior”. “No other group has a greater stake in buying smarter. But employers have always been reluctant actors in the health care system, as they feel out of their depth,” he explains.

Most employers are not in the health care business. Still, Galvin wants them to bargain more effectively with pharmacy benefit management (PBM) firms and health insurers. These expert intermediaries, he cautions, do not fully align their interests with those of their employer clients. At Equity Healthcare, Galvin negotiates for private-equity-owned employers like Toys R Us, Sea World, La Quinta and J.Crew.

Employers Forming Alliances

Large employers have been at the forefront of attempting to change health care. Still, even the pioneers and expert buyers among them are dissatisfied with their progress. Twenty of them have formed the Health Transformation Alliance, including value based insurance design pioneer Pitney Bowes and Caterpillar, which maintains its own prescription drug formulary.

“We’ve done what we can as individual companies. By joining together, we can do more,” said Marc Reed chief administrative officer of Verizon. The Alliance will serve as part of each company’s health strategy, fostering increased innovation, better data analyses and greater leverage to make the “current multilayered supply chain more efficient.” Their first project, slated for 2017: More affordable prescription medications.

Despite the involvement of companies like Pitney Bowes, Caterpillar, Verizon and other blue chip employers, some observers have given the Alliance a ho hum reception. Noting the already “crowded field” of business health groups, Forbes health correspondent Bruce Japsen observed, “it is just one of a number of similar, overlapping efforts that have so far failed to keep the rate of employer medical cost increases even on par with general inflation.”

Employers Working Locally

Prominent among other efforts are regional business health coalitions, represented nationally by the National Business Coalition on Health (NBCH). Board chair, Karen van Caulil, who also serves as CEO of the Florida Health Care Coalition, responded to the Alliance announcement with a suggestion.

“Our coalitions have been doing this work for years in their respective markets and have the regional intelligence and boots on the ground to make a difference. Many of the companies engaged in this new alliance are not involved in the regional coalitions and we would welcome them to play a more active role to bring about change in the communities where their employees live and work.”

The St. Louis Business Health Coalition also is the key driver of the Midwest Health Initiative (MHI), a broad-based, collaboration involving providers, payers, citizen groups, labor unions and employers. MHI stewards a data asset on regional on disease prevalence, care quality, and treatment patterns

Employers Aligning Nationally

On a national level, incoming NBCH CEO Michael Thompson believes “longer term reform, frankly, is going to come from the private sector aligning with the public sector,” which must take the lead. There is, he says, “a dire need for public programs like Medicare and Medicaid to get control of the situation.” Business should work at the local level, supporting engagement and driving change in their communities.

Such alignment could ensure health care purchasers – government and private – send clear and consistent signals to providers. However, it only makes sense with well-designed, proven payment models suitable for private sector application.

However, few employers currently are engaged in the Health Care Payment Learning and Action Network (HCP-LAN) established by CMS for public-private collaboration on value based payment initiatives. Pleading with employers to get involved, Wal-Mart’s Welborn says, “We need to be at the table with our best guess about what might work and then be willing to take a gamble, pilot a few ideas, and share outcomes.”

“We are highly encouraged by the willingness of our health system partners to engage with us and make investments that will support the changes needed to better deliver care, says Jeff White, Boeing’s director of health care strategy and policy.

Employees still have a choice between a Preferred Partnership and a more traditional plan. However, to encourage participation in the former, Boeing provides employees with incentives such as free primary care visits, lower employee paycheck contributions and higher company contributions to health savings accounts.

Participation has reached 35 percent in the Seattle area, where Boeing first launched the program, and ranges between 15 and 30 percent in the remaining markets. According to White, employee satisfaction is high, averaging 8.5 out of 10.

Intel, another, large, direct-contracting employer, “believes it is time for employers to work more directly to transform the payment and delivery systems for healthcare.” It has engaged directly and deeply in benefit design and delivery with Presbyterian Healthcare Services for its New Mexico employees.

Other large employers, like Lowes, Wal-Mart and McKesson, are participating in an Employer Centers of Excellence initiative through the Pacific Business Group on Health (PBGH) . They send employees directly to nationally recognized institutions like Johns Hopkins and Cleveland Clinic for orthopedic surgery and cardiac care.

Employers need not be large to contract directly – and successfully – with health systems, as employers of all sizes have found in Springfield, MO. There, the city government, local utilities, the public schools and Bass Pro Shops have deals with Mercy Springfield, which has been direct contracting with employers for 20 years. In fact, Mercy’s direct to employer business is its largest contract group.

Four years ago, Mercy began to accept limited risk. “We will give you basically a target and guarantee you less [cost] than where you’d expect to be in the next year,” David Cane, Mercy’s regional vice president of payer relations and contracting, explained to John Morrissey of Health Progress. “And if we don’t reach that, then at the end of the year, we’ll just write you a check for the difference, up to where the target was.” Morrissey reports that Mercy has yet to write a check.

Mercy apparently has a knack for working directly with employers. The Springfield hospital is one of the select few participating in the PBGH Centers of Excellence initiative. Meanwhile, the Mercy system in St. Louis, of which Mercy Springfield is a part, is Boeing’s direct contracting partner in St. Louis.

Perhaps the best way for an employer to become a better buyer is to collaborate with a better provider and together chase rainbows.

An intriguing question emerged from last week’s merger announcement from Walgreens Boots Alliance and Rite Aid. Led by CEO Stefano Pessina and his largely European executive team, will Walgreens be purveyor focused on retail sales or provider engaged with a transforming U.S. health care system?

The signals are mixed. A tea-leaf reading of last week’s investor call suggests Walgreens is destined to be a purveyor, focused on selling products and services. Today, however, Walgreens announced a big technology move that points to a provider future, closely integrated with payers and providers.

Purveyor or provider? Read on.

Tobacco: To Sell or not to Sell

“Are you considering eliminating tobacco,” Barclays Capital analyst Meredith Adler asked Walgreens president Alex Gourley during the investor call as the company fielded questions about earnings and the merger.

Gourley had just praised RiteAid for its new, sales-increasing wellness format, saying it was an opportunity for Walgreens, which also is seeing success with its new health, wellness and beauty positioning.

“It seems pretty clear,” said Adler, explaining her question, “that providers and payers feel uncomfortable working with a retail pharmacy that still sells tobacco.” In the background was the 2014 tobacco sales halt of CVS Health, which boasts 49 clinical affiliations, including Cleveland Clinic.

Gourley’s answer: No.

Walgreens would instead continue investing in smoking cessation. Anyway, he noted, only about three percent of all tobacco sales occur in a drugstore. He did not pivot to emphasize how Walgreens is working with providers and payers, notwithstanding tobacco sales.

A tea-leaf saying “purveyor”? Perhaps.

Outposts in Seattle

Gourley could easily have drawn the analyst’s attention to a Walgreens announcement just two months previously. In August, Walgreens and Seattle-based Providence Health & Services launched a new “strategic clinical collaboration.”

Providence will own and operate clinics in 25 Washington and Oregon Walgreens stores under its Providence and Swedish brand names. The first three will open in early 2016, with the remainder following in two years.

Rite Aid made a similar move in the Seattle market in May when it announced a joint venture between its RediClinic subsidiary and MultiCare Health System. The joint venture will operate clinics in 11 stores staffed by board certified MultiCare Nurse Practitioners in collaboration with MultiCare affiliated physicians.

Seattle, home to only three CVS stores, will provide a sheltered environment for Walgreens and Rite Aid to test the strategy of developing “deeper and more strategic relationships” with health systems. In particular, Providence is quite a catch, having directly contracted with Boeing to provide health care for the aircraft maker’s employees.

The EpicCare Connection

However, the nation’s 1,000 CVS MinuteClinics dwarf both Walgreens 400 Healthcare Clinics and Rite Aid’s small number of in-store RediClinics. Surpassing 25 million patient visits since the opening of its first clinic, CVS says it is opening three new MinuteClinics a week. Aiming for 1,500 clinics by 2017, CVS is acquiring all of Target’s 1,660 pharmacies and 80 clinics.

CVS is converting all of its MinuteClinics to the market leading EpicCare electronic medical records (EMR) system. Used broadly across health care, Epic also has strong interoperability with other EMR systems. This will provide seamless data exchange with most American hospitals.

“EpicCare will help us work more closely with physician practices as part of the medical home team, facilitate co-management of patients, and advance our mission to make health care more accessible, convenient and affordable for Americans,” said MinuteClinic chief medical officer Nancy Gagliano, M.D.

Dr. Patrick Carroll agrees. Today, the chief medical officer for Walgreens Healthcare Clinics announced the clinics would begin moving to EpicCare early next year. “As our clinics play an increasingly important role in health care, supporting the health care system, provider practices and patients’ medical homes, care coordination can be critical,” he echoed.

So, a provider future for Walgreens? It certainly looks like it. “This will benefit our patients, clinic providers and partners, and serves as an instrumental part of our strategic growth plan [emphasis added],” explained Carroll.

Confusing Signals

However, as recently as May, Walgreens quietly shuttered 35 clinics, a move two former employees described to Crains Chicago Business as signaling “uncertainty whether Walgreens really wants to spend more on primary care and in particular upgrading the clinics’ electronic medical record systems.” Today’s announcement erases some of that uncertainty, at least with respect to the EMR system.

In Seattle, Walgreens will provide in-store space, overseeing any needed build out. Providence will be using its own Epic system. “Patients will experience a seamless patient experience through our existing electronic health record system, providing direct connectivity to the clinics and billing systems, which will ensure better continuity of patient care and collaboration among providers,” said Providence senior vice president of physician services Mike Waters. Now, Walgreens will be able to connect directly.

Convincing Collaborations

In Seattle, a provider land lord; in Tampa, still a provider. There, Walgreens partners with a multi-specialty practice, assuming risk in an accountable care organization (ACO), Diagnostic Clinic Walgreens Well Network. Serving 7,500 patients, the ACO saved $1.5 million or 2% in costs. However, Walgreens has exited ACO partnerships with Baylor Scott & White in the Dallas-Fort Worth area and New Jersey’s Advocare. The company continues a clinical affiliation with Baylor Scott & White.

In Baltimore, Walgreens has a long-standing relationship with Johns Hopkins Medicine (JHM). The company provides grants for population health research overseen by a joint committee. Two years ago, it opened a store, including a Healthcare Clinic, adjacent to the JHM campus. In this case, Walgreens’ board certified nurse practitioners staff the clinic, although they and company pharmacists can work with JHM faculty.

Rite Aid’s Health Alliance program should dovetail nicely with Walgreens provider collaboration initiatives. The program brings together physicians, pharmacists and special care coaches to provide care and support to individuals with chronic and poly-chronic health conditions, helping them achieve health improvement goals established by their physicians.

Eight provider organizations currently are participating in Health Alliance, which leverages Rite Aid’s population health subsidiary, HealthDialog. Another 11 reportedly are be interested. On average, patients participating in the Rite Aid Health Alliance are 36% more adherent to their medications; they have lost an average of 7.7 pounds; they have a 39% reduction in blood pressure; and they have lowered their blood sugar by 36%, reports Drug Store News.

Big Bet on Consumer Technology

Rite Aid is also bringing Cleveland Clinic physicians into some of its Ohio stores via telehealth start up HealthSpot. Installed in the stores is a kiosk, enclosed for privacy, which includes a video connection with a physician and the capability to take and transmit vital signs to the physician.

Opting for mobile, Walgreens is using the Pager platform, designed by an early Uber architect, to connect customers with physicians. It also is relying on the MDLive platform for telemedicine, and working with WebMD on a wellness app, and with PatientsLikeMe enabling people to share medication experiences with each other.

Walgreens has been a leader in using technology to engage its customers. Its app is the third most downloaded retail app in the U.S. and the number one brick and mortar pharmacy app, reports mobihealthnews. Fourteen million people visit a Walgreens app or website each week and Walgreens fills more than one mobile prescription every second.

Walgreens’ Epic Catch-Up

However, until the EpicCare announcement today, Walgreens lagged in using technology to engage providers. Its electronic record system could not easily communicate with other systems, forcing stores to use secure fax and email to communicate with physicians and other providers. That raised serious questions about the future of its provider collaborations and role as a provider.

Now, EpicCare means Walgreens can be more than a purveyor. It can also be a provider, fully integrated into the new health care.

Scale has its limits, as the nation’s two largest pharmacy benefit managers (PBM) are discovering. Express Scripts and CVS Caremark each process more than a billion prescriptions a year. That is not enough for big customers Anthem and Aetna. Both are likely to alter dramatically or not renew long-term contracts set to end in 2019 with the PBM behemoths.

PBM Optionality for Anthem, Aetna

Anthem and Aetna say they now have “optionality” because Cigna and Humana, which they are respectively acquiring, both have PBMs. That optionality goes well beyond the scale Aetna would enjoy as the fourth largest PBM. It can put the pharmacy benefit, integrated within each organization, on the path to value-based health care.

Both the Humana and Cigna PBMs align well with the quality and outcomes focus of value-based health care. Humana’s PBM primarily supports the company’s Medicare Advantage (MA) and Part D programs, with MA accountable care arrangements delivering better outcomes than traditional Medicare.

Meanwhile, Cigna has pioneered outcomes-based reimbursement arrangements with pharmaceutical manufacturers. Previously overseeing Cigna’s PBM was none other than Aetna CEO Mark Bertolini; Cigna CEO David Cordani will serve as chief operating officer of the new Anthem.

In fact, the very tools used to leverage scale to get lower prices, such as formulary exclusions, can potentially work against reducing total costs. In securing a substantial discount from AbbVie for Viekira Pak, Express Scripts excluded Gilead’s Harvoni from its 2015 formulary. Viekira Pak is a four pill a day regimen to Harvoni’s adherence-friendly one pill for curing hepatitis C.

Not surprisingly, given their focus on overall costs, Aetna, Anthem, UHG and Cigna all included Harvoni on their formularies and do not publish exclusion lists like Express Scripts and CVS Caremark. Instead, they typically establish clinically based prior authorization criteria.

For the latest high-cost drugs to hit the market, Express Scripts is following the health plans on their value path. Instead of excluding one of two new anti-cholesterol drugs, known as PCSK9 inhibitors and list priced at $14,000 per year, it announced coverage for both this week.

As the health plans did with Harvoni, Express Scripts will implement rigorous prior authorization procedures. The company says it negotiated good pricing with Amgen for Repatha and with Sanofi and Regeneron Pharmaceuticals for Praluent, enabling it to cover both drugs. Perhaps it also heard from customers unhappy with price-driven drug exclusions.

Wanting More, Customers Become Competitors

Clearly, some very big customers – Aetna, Anthem and UHG – want something more than scale from traditional PBMs like Express Scripts and CVS Caremark. Beyond scale, they want a pharmacy benefit that contributes to reducing total costs through better outcomes, consistent with achieving overall value-basedpayment goals.

Building PBM paths to value-based health care for themselves, Anthem, Aetna and UHG will also sell against volume-based models like those of Express Scripts and CVS Caremark, and against health plans that fail to integrate pharmacy and medical claims for actionable intelligence.

Employers and the Limits of Scale

Their strategy blueprint could easily have come from the Harvard Business Review article “The Limits of Scale.” Hanna Halaburda and Felix Oberholzer-Gee argue that, when rapidly scaling companies neglect to take into account differences among their customers, performance declines. On that premise, they suggest how challengers and incumbents can take advantage of customer differences.

Among PBM customers with differences are employers, which provide health coverage for 147 million Americans. The National Business Coalition on Health is uneasy with the growing use of exclusionary formularies. It advises members to “base selection criteria for formularies on clinical outcomes to ensure that pharmaceutical costs do not decrease at the expense of rising medical costs.”

Employers are becoming more actively engaged in managing the pharmacy benefit, even developing their own formularies and negotiating directly with pharmacy retailers. Caterpillar’s Daren Hinderman told an NBCH panel last year, “I don’t want to have a conversation [with PBMs] on rebates; I want to have a conversation on how I can keep my employees more compliant with medications they need to stay healthy. We decide what’s best for our employees. It’s a transparent process.”

NBCH also urges members to “verify that pharmacy and medical benefits are aligned, and link data between the two in order to evaluate cost and outcomes across both types of benefits and the entire health-care spectrum, not just through the lens of pharmacy.” As Dr. Mark Fendrick of the University of Michigan Center for Value-Based Insurance Design told the NBCH panel, “I’d prefer to spend more on statins than on stents.”

Obstacles on PBM Value Path

Mapping the PBM path to value-based health care is one thing, building it is another. Aetna and Anthem still must face a gauntlet of government and legal reviews before they can complete their acquisitions and commence integrating the Humana and Cigna PBMs.

Meanwhile, the Catamaran acquisition has roiled a PBM industry where many participants use Catamaran’s RxClaim platform – including Cigna! They were content to compete with Catamaran, despite using its technology. However, will they be similarly comfortable with OptumRx and UHG in the technology driver’s seat?

Much like UHG’s acquisition of Catamaran and its technology, Rite-Aid did the same when it acquired EnvisionRx. The PBM had previously acquired Laker Software, also a claims platform supplier for many PBMs. Again, the comfort question arises, in this case over Envision and Rite Aid as the drug retailer pursues its path to value-based health care via innovative alliances with health care providers.

Making the Laker and RxClaim platforms particularly valuable has been the PBM industry’s reliance on a hodge podge of decades-old, antiquated platform technologies. With each acquisition, scaling PBMs have patched together instead of invested in their platforms to maximize short-term synergies, at the cost of limited flexibility and lower efficiency.

PBMs Miss Technology Revolutions

Meanwhile, multiple revolutions have coursed through the systems development world since the PBM industry acquired its mainframes and data centers in the late 1980’ – early 1990’s. When relational databases followed soon thereafter, PBMs adopted them for after-the-fact data analysis, but not broadly for real time use with claims processing platforms, which now are antiquated and fragmented.

More recently, graphical user interfaces have greatly streamlined the programming of business intelligence applications. It is now easier for more people, more efficiently to translate their expertise into innovative systems. No longer must visionaries exclusively funnel their solutions through highly specialized programmers and coders. Now, the visionaries’ can become coders, their hands on the programming controls, unleashing new applications across the entire economy, including the PBM industry.

PBM Platform for Value-Based Health Care

One such visionary has developed a PBM solution for value-based health care. His name is Ravi Ika. “The solution is holistic, unlike that of any other existing PBM. It reduces overall pharmacy cost, converts specialty from ‘buy & bill’ to ‘authorize and manage,’ and lowers avoidable drug-impacted medical costs,” explains Ika.

Before turning his attention to the PBM industry, he created a comprehensive, integrated payer platform now provided by ikaSystems, which he founded to transform the payer operating model. Spanning all payer departments and business lines, it decreased administrative costs for health insurers by as much as 50% and reduced avoidable medical costs.

In 2013, Ika launched RxAdvance, a full service PBM, which similarly operates on an integrated, end-to-end platform – one designed specifically for value-based health care. Combining pharmacy, medical, and lab data, the platform – called PBM Collaborative Cloud– enables real-time engagement. This engagement occurs with physicians at the point of care, pharmacists at the point of sale, and patients via mobile cloud. It also engages payers clinical and pharmacy staff through their workflows.

PBM Processes Reimagined

“We started with a clean slate,” observes Ika, who says he and his team reimagined PBM processes to streamline workflow before building the platform. Redefining the human role, they automated as much as possible while, on the other hand, increasing opportunities for engagement, what-if modeling, and informed decision-making. The platform also enables market and regulatory changes configurable by the business user, as well as system-driven compliance management.

Ika built the platform from the ground up using a unified data model. In information technology parlance, that means the platform’s standards are universal enough to encompass a large scope of data and types of data with high scalability.

From Existing to Ideal Formularies

For example, the platform includes algorithm-driven artificial intelligence to manipulate, with plan sponsor engagement, the complex and interdependent variables associated with formulary management. Incorporating habitual member and prescriber utilization patterns, in addition to other data, it derives an ideal formulary with optimal financial and clinical outcomes. The system then maps a transition plan from an existing formulary. The platform also accommodates an unlimited number of formularies and supports real time dynamic modeling and changes coupled with full transparency.

Better Medication Therapy, Adherence Outcomes

For medication therapy management (MTM), the platform taps patient medical claims and disease conditions, against which the system overlays a prescription listing for easy use by prescribers. In addition, each new prescription triggers a dynamic analysis to determine patient eligibility for a comprehensive medication review (CMR), which the system prepopulates for efficient prescriber use.

After the CMR, RxAdvance advisors rely on system alerts to intervene with patients to ensure medication adherence. For high-risk patients, RxAdvance will install an electronic, patent-pending pill station at their residences and resupply it with disposable pre-filled pill trays.

Integrated with and wirelessly connected to the company’s platform, the device assists with monitoring adherence and vital signs. The company says the device has improved adherence to more than 93%, including patients with multiple chronic conditions who are taking an average of 15 medications a day.

The Centers for Medicaid and Medicare Services (CMS) recently underscored the PBM need for physician-led, point-of-care MTM capability when it announced a new Medicare Part D MTM model. Currently, highly fragmented PBM MTM relies on pharmacists “chasing” patients without closing the loop with prescribers, thus failing to secure meaningful health outcomes, according to Ika.

Ika points to the RxAdvance specialty management program as another example of his platform’s capabilities. As it does for MTM, the platform integrates prescriptions, medical claims and disease conditions to create an action plan for all stakeholders. Case managers use a dashboard to prioritize their outreach to patients, prescribers and pharmacists. Because the platform integrates medical, pharmacy and lab information, it helps facilitate appropriate utilization.

Risk Sharing

One of the hallmarks of an organization configured for value-based health care is its ability to share risk. The RxAdvance unified data model platform enables it to share risk for both pharmacy and avoidable drug-impacted medical costs. For pharmacy, it is prepared to assume both up and down side risk based on its cost management performance against a risk cap set below a national benchmark projected increase.

The company can also compute a baseline trend for avoidable drug-impacted medical costs using prior years’ medical claims data. RxAdvance and its client then set a target and, if the PBM lowers actual avoidable drug-impacted medical costs, it will share in the savings. According to Ika, this sort of risk sharing is unique in the PBM market.

Ika reports that RxAdvance is currently implementing full PBM services for three clients, replacing national PBMs. “The Collaborative PBM Cloud platform is making for a very smooth launch,” he notes.

RxAdvance has gotten a head start along the PBM path to value-based health care, scaling the limits of scale.

In a new poll released yesterday, the Kaiser Family Foundation reported that large majorities of Americans, regardless of political party, think drug prices are unreasonably high, drug companies put profits before patients, and government should limit the cost of high priced drugs and negotiate lower prices for Medicare.

However, the same poll found that 76% of Republicans preferred market competition over government regulation to lower drug prices. In addition, while 74% of Republicans say the government should directly negotiate Medicare drug prices, a smaller number – 56% — believe it can be effective.

Perhaps this explains why Republican candidates for President have not addressed high drug prices, preferring instead to focus on Obamacare repeal, as reported by Politico. Neither Scott Walker nor Marco Rubio have included drug prices in their Obamacare replacement proposals.

Will Donald Trump take on high drug prices? If he does, what would he say? Whatever he says about an issue quickly frames how other Republican candidates and the news media speak about it. Such is Trump’s dominance of the daily news cycle. That alone makes the question relevant and the answer useful.

He is also more in tune with the Republican base than the party’s establishment may want to admit, as political commentator Ezra Klein observed earlier this week. Trump is the only Republican candidate who opposes cuts in Medicare, Social Security and Medicaid, a long-held position he directly links to making American strong again.

Interviewed on Larry King in 1999, he said, “What’s the purpose of a country if you’re not going to have defense and healthcare. If you can’t take care of your sick in the country, forget it, it’s all over. I mean, it’s no good.” He told the Iowa Freedom Summit earlier this year, “I want to make the country rich so that Social Security can be afforded, and Medicare and Medicaid.”

Recently, on Meet the Press, he said, “I want people to be taken care of from a health-care standpoint. But to do that, we have to be strong. I want to save Social Security without cuts. I want a strong country. And to me, conservative means a strong country with very little debt.”

In fact, Trump comes across as a Robin Hood, putting himself on the side of American citizens, taking money from wealthy countries he says rightfully belongs to us, fighting government corruption and stupidity, and expelling illegal aliens (to use his terminology). He is also a deal maker, exploiting leverage or creating advantage to get what he wants.

What, then, would Donald Trump say about high drug prices? To answer that question, here is an imagined Meet the Press conversation between host Chuck Todd (imagined) and Donald Trump (imagined). It suggests Donald Trump could easily take high cost drugs to a place neither the other Republican candidates nor the drug industry want to go.

Chuck Todd (Imagined):

Mr. Trump, in a new poll, 70% of Republicans want the government to limit how much pharmaceutical companies can charge for high-cost cancer drugs. What would you do about the high cost of prescription drugs?

Donald Trump (Imagined):
Repeal Obamacare and replace it with something terrific. It’s a disaster. It’s virtually useless and big lie. Deductibles are through the roof and costs are going up.

Chuck Todd (Imagined):

How would repealing Obamacare lower drug costs? They’re growing faster than other health costs – mainly because of the new specialty drugs – but they still only account for 10% of all health spending.

Donald Trump (Imagined):

Chuck, the drug company lobbyists did a fantastic job when Congress passed Obamacare. They out-negotiated the President and got a great deal. They supported Obamacare and agreed to help pay for it. In return, they got more customers and higher prices. When I repeal and replace Obamacare, the pharma companies will have to negotiate with me.

Chuck Todd (Imagined):

Does that mean you support letting the government directly negotiate with drug companies over the prices it pays for Medicare drugs?

Donald Trump (Imagined):

Medicare is the largest single buyer of prescription drugs. In business, a best customer gets the best deal. When I buy televisions for my hotels, which I sadly can’t get in the US but that’s another issue, I use that leverage for a great price. Yes I’d negotiate better prices with the drug companies. But, it’d be different, like a business, not as price controls or more regulations in disguise. You’ll be very pleased, very pleased with how I do it.

Chuck Todd (Imagined):

But, what about the cost of drugs not covered by Medicare….these new cancer drugs that cost thousands of dollars. In fact, the doctors who treat cancer are campaigning for lower prices.

Donald Trump (Imagined):

Chuck, I’ve got a deal where everyone wins. I love the drug companies. They’ve made great discoveries and cured many people. I want the drug companies to create jobs in the US, making new drugs. That takes money. They hold almost a half-trillion dollars outside the United States because the taxes on bringing it home are too high. Bring those dollars home, use them for jobs, discover new cures, keep prices under control and I’ll lower the taxes.

Chuck Todd (Imagined):

Republicans also think Americans should be able to buy prescription drugs imported from Canada, and by a wider margin than Democrats: 75% Republicans vs. 69% Democrats. What do you think of that?

Donald Trump (Imagined):

The problem is much bigger. What our pharmaceutical industry accomplishes is tremendous. It benefits the entire world but prices are highest in the United States. Per person, we spend twice as much as other wealthy nations. It’s time other nations paid their fair share. As you know, rich nations like Saudi Arabia must pay us back for what the Defense Department spends on protecting them. Canada, the European Union and other wealthy nations should help pay for our National Institutes of Health. The American taxpayer funds 85% of basic research. We have to stop subsidizing their health care.

Chuck Todd (Imagined)

The drug industry says that it needs to charge high prices because it takes so long to bring a drug to market. Would you make any changes at the FDA?

Donald Trump (Imagined)

The FDA needs to do a better job on safety, especially after a drug is on the market. Take vaccines, I don’t think kids should get them all at once. Spread them out. It doesn’t hurt anybody other than probably the pharmaceutical companies because they probably make more money putting it into one shot. I want more approvals and more competition. That will bring prices down.

Chuck Todd (Imagined):

Speaking of health care. Earlier, you said you would repeal and replace Obamacare. How would you replace Obamacare?

Donald Trump (Imagined):

I believe in universal healthcare. I believe in whatever it takes to make people well and better. What’s the purpose of a country if you’re not going to have defense and healthcare? We can have something far better for the people, and far less expensive, both for the people and for the country. And believe me there are plans that are so much better for everybody. And everybody can be covered. I’m not saying leave 50-percent of the people out.

Chuck Todd (Imagined):

How would you pay for it?

Donald Trump (Imagined)

Get tough with the big players like China and OPEC that are ripping us off so we can recapture hundreds of billions of dollars to pay our bills, take care of our people, and get us on a path toward serious debt reduction. We must take care of our own people—we must make our country strong and rich again so that Social Security, Medicare, and Medicaid will no longer be thought of as a problem. We must save these programs through strength, power, and wealth.

Chuck Todd (Imagined):

During the debate, you seemed to speak favorably about single payer systems in Scotland and elsewhere. Do you favor a single payer system in the United States?

Donald Trump (Imagined):

No. What we need in the United States is free market plan that provides consumer choice, keeps plans portable and affordable and returns authority to the states. We also must break the insurance company monopolies and allow individuals to purchase health insurance across state lines.